Validation of CRIB II for prediction of mortality in premature babies

Neonatal death prediction scores: a systematic review and meta-analysis

OBJECTIVE

To compare, through a systematic review and meta-analysis of observational accuracy studies, the main existing neonatal death prediction scores.

METHOD

Systematic review and meta-analysis of observational accuracy studies. The databases accessed were MEDLINE, ELSEVIER, LILACS, SciELO, OpenGrey, Open Access Thesis and Dissertations, EMBASE, Web of Science, SCOPUS and Cochrane Library. For qualitative analysis, Quality Assessment of Diagnostic Accuracy Studies 2 was used. For the quantitative analysis, the area under the curve and the SE were used, as well as the inverse of the variance as a weight measure, DerSimonian and Laird as a measure of random effects, Higgins' I² as an estimate of heterogeneity, Z as a final measure with a 95% confidence level.

RESULTS

55 studies were analysed, 8 scores were compared in a total of 193 849 newborns included. The most accurate neonatal death prediction score was Score for Neonatal Acute Physiology Perinatal Extension II (SNAPPE II) (0.89 (95% CI 0.86 to 0.92)) and the least accurate was gestational age (0.75 (95% CI 0.71 to 0.79)).

CONCLUSION

SNAPPE II was the most accurate score found in this study. Despite this, the choice of score depends on the situation and setting in which the newborn is inserted, and it is up to the researcher to analyse and decide which one to use based on practicality and the possibility of local implementation. Given this, it is interesting to carry out new prospective studies to improve the prediction of neonatal deaths around the world.

PROSPERO REGISTRATION NUMBER

CRD42023462425.

Comparison of CRIB-II with SNAPPE-II for predicting survival and morbidities before hospital discharge in neonates with gestation ≤ 32 weeks: a prospective multicentric observational study

Various studies validated and compared Score for Neonatal Acute Physiology with Perinatal extension-II (SNAPPE-II) and Clinical Risk Index for Babies-II (CRIB-II) admission sickness severity scores for predicting survival, but very few studies compared them for predicting the morbidities in preterm infants. In this multicenter prospective observational study, SNAPPE-II and CRIB-II newborn illness severity scores were compared for predicting mortality and morbidities in infants with gestational age of ≤ 32 weeks. Major morbidities were classified as bronchopulmonary dysplasia, abnormal cranial ultrasound (presence of intraventricular hemorrhage grade III or more or periventricular leukomalacia grade II to IV), and retinopathy of prematurity requiring treatment. Combined adverse outcome was defined as death or any major morbidity. Comparison of the scoring systems was done by area under the curve (AUC) on receiver operating characteristics curve (ROC curve) analysis. A total of 419 neonates who were admitted to 5 participating NICUs were studied. The mortality rate in the study population was 8.8%. Both CRIB-II (AUC: 0.795) and SNAPPE-II (AUC: 0.78) had good predictive ability for in-hospital mortality. For predicting any one of the major morbidities and combined adverse outcome, CRIB-II had better predictive ability than SNAPPE-II with AUC of 0.83 vs. 0.70 and 0.85 vs. 0.74, respectively.

CONCLUSION

In infants with gestational age of ≤ 32 weeks, both CRIB-II and SNAPPE-II are good scoring systems for predicting mortality. CRIB-II, being a simpler scoring system and having better predictive ability for major morbidities and combined adverse outcome, is preferable over SNAPPE-II.

WHAT IS KNOWN

• SNAPPE-II and CRIB-II scores have good predictive ability on in-hospital mortality in preterm neonates.

WHAT IS NEW

• SNAPPE-II and CRIB-II both have good predictive ability for mortality, but CRIB-II has better ability for short-term morbidities related to the prematurity.

Prognostic Models Predicting Mortality in Preterm Infants: Systematic Review and Meta-analysis

CONTEXT

Prediction models can be a valuable tool in performing risk assessment of mortality in preterm infants.

OBJECTIVE

Summarizing prognostic models for predicting mortality in very preterm infants and assessing their quality.

DATA SOURCES

Medline was searched for all articles (up to June 2020).

STUDY SELECTION

All developed or externally validated prognostic models for mortality prediction in liveborn infants born <32 weeks' gestation and/or <1500 g birth weight were included.

DATA EXTRACTION

Data were extracted by 2 independent authors. Risk of bias (ROB) and applicability assessment was performed by 2 independent authors using Prediction model Risk of Bias Assessment Tool.

RESULTS

One hundred forty-two models from 35 studies reporting on model development and 112 models from 33 studies reporting on external validation were included. ROB assessment revealed high ROB in the majority of the models, most often because of inadequate (reporting of) analysis. Internal and external validation was lacking in 41% and 96% of these models. Meta-analyses revealed an average C-statistic of 0.88 (95% confidence interval [CI]: 0.83-0.91) for the Clinical Risk Index for Babies score, 0.87 (95% CI: 0.81-0.92) for the Clinical Risk Index for Babies II score, and 0.86 (95% CI: 0.78-0.92) for the Score for Neonatal Acute Physiology Perinatal Extension II score.

LIMITATIONS

Occasionally, an external validation study was included, but not the development study, because studies developed in the presurfactant era or general NICU population were excluded.

CONCLUSIONS

Instead of developing additional mortality prediction models for preterm infants, the emphasis should be shifted toward external validation and consecutive adaption of the existing prediction models.

Comparing mortality risk models in VLBW and preterm infants: systematic review and meta-analysis

OBJECTIVE

To compare the prognostic accuracy of six neonatal illness severity scores (CRIB, CRIB II, SNAP, SNAP II, SNAP-PE, and SNAP-PE II), birthweight (BW), and gestational age (GA) for predicting pre-discharge mortality among very low birth weight (VLBW) infants (<1500 g) and very preterm infants (<32 weeks' gestational age).

STUDY DESIGN

PubMed, EMBASE, and Scopus were the data sources searched for studies published before January 2019. Data were extracted, pooled, and analyzed using random-effects models and reported as AUC with 95% confidence intervals (CI).

RESULTS

Of 1659 screened studies, 24 met inclusion criteria. CRIB was the most discriminate for predicting pre-discharge mortality [AUC 0.88 (0.86-0.90)]. GA was the least discriminate [AUC 0.76 (0.72-0.80)].

CONCLUSIONS

Although the original CRIB score was the most accurate predictor of pre-discharge mortality, significant heterogeneity between studies lowers confidence in this pooled estimate. A more precise illness severity score to predict pre-discharge mortality is still needed.

Predicting mortality in extremely low birth weight infants: Comparison between gestational age, birth weight, Apgar score, CRIB II score, initial and lowest serum albumin levels

We explored GA, BW, Apgar score, CRIB II score, and serum albumin levels as univariate predictors of mortality in extremely low birth weight infants. Medical records of 564 extremely low birth weight infants were reviewed retrospectively. The infants were grouped as survivors (group I), expired ≤ 7^th postnatal day (group II), and expired > 7^th postnatal day (group III). The predictive value for mortality of gestational age, birth weight, Apgar scores at 1 and 5 min, clinical risk index for babies II score, and first and lowest serum albumin levels was assessed by calculating the associated area under the curve (AUC) in receiver operating characteristic (ROC) curves. The overall survival and mortality rates of groups I, II, and III were 81.0% (457/564), 7.6% (43/564), and 11.4% (64/564), respectively. Birth weight, Apgar scores at 1 and 5 min, and first serum albumin levels were significantly higher, while the clinical risk index for babies II score was significantly lower in group I when compared to groups II and III. Gestational age and lowest serum albumin level in group I were significantly higher than group III, but not group II. However, gestational age, birth weight, and clinical risk index for babies II score showed gestational age dependent variations regardless of survival or mortality. Apgar score at 5 min (0.756) and lowest serum albumin level (0.771) demonstrated the highest AUC of the ROC curve in predicting mortality in group II and III, respectively. In conclusion, Apgar score at 5 min and lowest serum albumin level were the most effective predictors for mortality in extremely low birth weight infants during ≤ 7^th and > 7^th postnatal days, respectively.

Diagnosis and Risk Factors of Acute Kidney Injury in Very Low Birth Weight Infants

BACKGROUND

Acute kidney injury (AKI) is common in critically ill premature infants. There is a lack of consensus on the diagnostic definition of AKI in very low birth weight (VLBW) infants. The primary aim of this study was to determine the incidence and risk factors for AKI in VLBW infants using the AKI network (AKIN) and pRIFLE (pediatric Risk, Injury, Failure, Loss, End-Stage) criteria and to evaluate whether Clinical Risk Index for Babies (CRIB II) score is a predictor of AKI. The secondary objective was to determine the extent of agreement between the AKIN and pRIFLE criteria in the diagnosis of AKI in VLBW infants.

METHODS

This was a retrospective chart review of 115 VLBW (< 1500 g) infants born in an academic center with a Level 3B neonatal intensive care unit. Multiple congenital anomalies, transfer to other centers, or death within the first 2 weeks were the exclusion criteria. Relevant data were collected and analyzed in the first 2 weeks postnatally.

RESULTS

AKI incidence, according to AKIN and pRIFLE criteria, was 20.1% and 22.6%, respectively. As per the interrater reliability analysis, there was a fair agreement between the two criteria (kappa = 0.217). AKI was nonoliguric. The length of stay was significantly longer in the AKI group. Prenatal nonsteroidal anti-inflammatory drug exposure, lower gestational age, lower birth weight, respiratory distress syndrome, mechanical ventilation, patent ductus arteriosus, hypotension, late onset sepsis, and higher CRIB II scores were significantly associated with AKI. Our regression analysis found CRIB II scores to be an independent risk factor for AKI (odds ratio = 1.621; 95% confidence interval, 1.230-2.167; p = 0.001).

CONCLUSION

The determination of AKI using the pRIFLE and AKIN criteria yielded different results. pRIFLE appears to be more sensitive in VLBW infants. A high CRIB II score was recorded for AKI. Future studies are necessary to develop a uniform definition and identify the risk factors to improve the outcomes in this population.

Assessment of sickness severity of illness in neonates: review of various neonatal illness scoring systems

Sickness severity scores are widely used for neonates admitted to neonatal intensive care units to predict severity of illness and risk of mortality and long-term outcome. These scores are also used frequently for quality assessment among various neonatal intensive care unit and hospital. Accurate and reliable measures of severity of illness are required for unbiased and reliable comparisons especially for benchmarking or comparative quality improvement care studies. These scores also serve to control for population differences when performing studies such as clinical trials, outcome evaluations, and evaluation of resource utilisation. Although presently there are multiple scores designed for neonates' sickness assessment but none of the score is ideal. Each score has its own advantages and disadvantages. We did literature search for identifying all neonatal sickness severity score and in this review article, we discuss these scores along with their merits and demerits.

Evaluation of Score for Neonatal Acute Physiology and Perinatal Extension II and Clinical Risk Index for Babies with additional parameters

BACKGROUND

The aim of this study was to determine mortality risk by calculating Score for Neonatal Acute Physiology and Perinatal Extension II (SNAP-PE-II) and Clinical Risk Index for Babies (CRIB) score, and evaluate prediction of the effects of antenatal corticosteroid and surfactant treatment on mortality.

METHODS

This multicenter study was conducted simultaneously in five different centers in four different provinces in Southern Turkey between July 2012 and July 2013. A total of 1668 inborn subjects hospitalized in the neonatal intensive care unit within the first 12 h of delivery, and meeting the selection criteria, were included in the study, and CRIB and SNAP-PE-II were used to determine mortality.

RESULTS

The SNAP-PE-II scoring system was applied to all patients, and the CRIB scoring system was used for 310 newborns with gestational age <32 weeks and weighing <1500 g. Of the 1668 patients, 188 died (mortality rate, 11.3%). Cut-off was found to vary with center, which changed specificity and sensitivity of the mortality scores. SNAP-PE-II significantly predicted mortality (P < 0.05) compared with CRIB. SNAP-PE-II also successfully predicted mortality in the group receiving antenatal corticosteroid compared with the group not receiving antenatal corticosteroid.

CONCLUSION

SNAP-PE-II was a significant predictor of mortality in newborns with birthweight <1500 g compared with CRIB, and assessment of antenatal corticosteroid use in conjunction with SNAP-PE-II increased the accuracy of the prediction of mortality.

Clinical Risk Index for Babies (CRIB II) Scoring System in Prediction of Mortality in Premature Babies

BACKGROUND

Clinical Risk Index for Babies scoring system (CRIB II) score is a recently developed tool to predict initial risk of mortality amongst low birth weight babies, the utility of which is scarce in many developing countries.

OBJECTIVE

To assess the efficiency of CRIB II score as a tool to predict the risk for neonatal mortality among the LBW babies admitted to neonatal intensive care unit (NICU) at a tertiary care facility Kasr El-Aini paediatric hospital, Cairo, Egypt.

MATERIALS AND METHODS

Prospective cohort study design where 113 neonates, admitted during the first 24 hours to the NICU of Kasr El-Aini Hospital, from November 2013 till May 2014 were included. On admission, history taking, neonatal examination, arterial blood gas analysis and variables of CRIB II score were done. Subjects were followed up from admission till discharge or death.

RESULTS

Male to female ratio was 1.1:1. Gestational age ranged from 25-32 weeks, the birth weight ranged from 700-1500 gm with mean of 1134.5 (± 202). CRIB II score ranged from 1-19 with a mean of 9.9 (± 4.0). The total mortality in the included cohort was 34.5% (31/113). Significant positive correlations were found between gestational age, birth weight, temperature, excess base, CRIB II score and the occurrence of mortality and with progressive increase in mortality with increasing CRIB II score (p=0.001). CRIB II score ≥ 11, gestational age ≤ 28 and birth weight ≤ 1100 were all found to be significantly associated with neonatal mortality. Area under ROC curve for CRIB II, gestational age and birth weight were found to be (0.968, 0.900 and 0.834) respectively. CRIB II score with cutoff point of ≥ 11 was the most sensitive (94.9%) with the predictive value (74.0%) and specificity (82.4%) compared to birth weight and gestational age. CRIB II score showed good calibration to predict neonatal mortality as demonstrated with Hosmer-lemeshow goodness of fit test (p= 0.952).

CONCLUSION

CRIB II score is a valid tool of initial risk assessment in LBW, predicting outcome more accurately than birth weight or gestational age alone. It is easily applicable and should replace the traditional models as predictor of neonatal outcome.

What really causes necrotising enterocolitis?

Background. One of the most serious gastrointestinal disorders occurring in neonates is necrotising enterocolitis (NEC). It is recognised as the most common intra-abdominal emergency and is the leading cause of short bowel syndrome. With extremely high mortality and morbidity, this enigmatic disease remains a challenge for neonatologists around the world as its definite aetiology has yet to be determined. As current medical knowledge stands, there is no single well-defined cause of NEC. Instead, there are nearly 20 risk factors that are proposed to increase the likelihood of developing NEC. Aims and Objectives. The aim of this project was to conduct a comprehensive literature review around the 20 or so well-documented and less well-documented risk factors for necrotising enterocolitis. Materials and Methods. Searches of the Medline, Embase, and Science direct databases were conducted using the words "necrotising enterocolitis + the risk factor in question" for example, "necrotising enterocolitis + dehydration." Search results were ordered by relevance with bias given to more recent publications. Conclusion. This literature review has demonstrated the complexity of necrotising enterocolitis and emphasised the likely multifactorial aetiology. Further research is needed to investigate the extent to which each risk factor is implicated in necrotising enterocolitis.